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Safer Spinal Intrathecal Devices

Updated February 2013

The Safe Anaesthesia Liaison Group (SALG) has acknowledged the concerns of the specialty surrounding National Patient Safety Agency (NPSA) alerts on spinal, epidural and regional devices. The President of the College jointly signed an updated statement in February 2013. The correspondence between the College and other national bodies and a series of frequently asked questions on this topic can be found on the Obstetric Anaesthetists Association (OAA) website.

SALG would like to remind anaesthetists not to use equipment that they are unfamiliar with or which hasn’t been sufficiently tested. SALG would also like to offer the following suggestions by way of advice when implementing the NPSA guidelines. Each department should ensure that:

the Trust has nominated an Executive Director too oversee implementation

a scoping exercise has been conducted to determine what equipment is covered by the alerts

other specialties that may be affected are aware of the alerts

risk registers are updated and reviewed regularly if implementation is not possible.

SALG also recommend that medical staff read the relevant articles published in the November 2010 issue of Anaesthesia, which are downloadable below:

Please also see five editions of the Neuraxial Update newsletter, by Professor David Cousins at the NPSA, which are available on the Patient Safety First website. The updates provide important information regarding the successful implementation of the alerts and should be shared as widely as possible.

Non-Luer Spinal Devices Evaluation – please take part

The Obstetric Anaesthetists Association (OAA), in partnership with the Safe Anaesthesia Liaison Group (SALG), have developed an evaluation system for new spinal (intrathecal), epidural and regional devices. In light of the January and November 2011 alerts requiring a change to non-Luer connectors, a number of new products have, and continue to, become available.

OAA and SALG consider specialty input crucial to the ergonomic success of new equipment and urge you to take this opportunity to feedback on new kit. Information on the evaluation and the evaluation form can be found on the OAA website.

The identity (including hospital) of the person submitting is not required but may be helpful. If the reporter’s details are included with the submission they will not be displayed publically. This evaluation does not replace incident reporting to the NPSA or MHRA. Therefore please follow your normal reporting procedure in the event that a patient safety incident results from the use of these devices. If a report has been submitted to MHRA or the NPSA, this must be specified on the OAA return.

The Leicester assessment package for non-Luer neuraxial equipment

This section contains two assessment forms, one clinical and one for a bench-top model. They have been used in the product evaluation tests of seven non-Luer neuraxial needles in the University Hospitals of Leicester NHS Trust. Data from these evaluations was presented at the Obstetric Anaesthetists Association meeting held at the Royal College of Anaesthetists in September 2012 and will be shown in full in the Journal Anaesthesia in 2013. Clinicians are free to use these forms to evaluate non-Luer products in their own hospitals and share the data centrally to help build up a National database to further aid purchasing choice and safety logging.